| Dental Cleaning - Adult | $99 | 0% | $99 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $48 | 0% | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $167 | 0% | $167 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $302 | 0% | $302 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - White (Resin): One Surface, Anterior | $146 | 0% | $146 |
| Dental Filling - White (Resin): One Surface, Posterior | $167 | 0% | $167 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $182 | 0% | $182 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $232 | 0% | $232 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $145 | 0% | $145 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $255 | 0% | $255 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
| Root Canal - Molar | $1,104 | 0% | $1,104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $173 | 0% | $173 |
| X-Ray - Complete Intraoral Series | $141 | 0% | $141 |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
